Treatment of myasthenia gravis with adrenocorticotropic hormone (ACTH): massive short-term and maintenance treatment.

The management of severe myasthenia gravis presents a continuing challenge to the physician.Even with the most careful adjustment of anti- cholinesterase medication the patient may become severely disabled.Thymectomy seems to offer real benefit to some of the carefully selected patients.However, despite the careful employment of anti- cholinesterase medication and the improvement after some thymectomies, some patients still cannot be adequately controlled and become severely disabled and die.In 1951 Torda and Wolff treated these refractory myasthenia patients with ACTH.They obtained a 'significant partial remission' after corticotropin therapy in 10 of 15 patients.They recognized, however, that a transient and sometimes severe exacerbation of weakness was apt to occur during the first days of treatment.One of their 15 patients died during such an exacerbation.Their report was directly contradicted by Grob and Harvey, who reported in 1952 that in none of their 10 patients was any increase in strength observed either during or after ACTH administration.In subsequent years, however, there have been additional reports (Grob and Namba, 1966;Osserman and Genkins, 1966; von Reis, Liljestrand, and Matell, 1966) of remissions lasting three months or longer.Such remissions were more consistent after massive doses of ACTH.von Reis et al. (1966), for example, gave 1,000 u.ACTH over a period of six to 12 days to 13 patients and obtained excellent results in 23 out of 33 courses of treatment.Ample clinical experience has shown that massive doses of ACTH will often bring about a remission when myasthenia is otherwise refractory to medi- cation.The reports have uniformly noted that initiation of treatment carries danger because of transient increase of weakness, and all have lamented the brevity of the remission which might 'This paper was read at the meeting of the Memphis Neurological Society, Memphis, Tennessee, 8 June, 1968.